War in Ukraine impacts immunisation
Authors: Ed Holt
Journal: The Lancet Microbe (2023)

A polio outbreak in Ukraine that began in October 2021 was declared closed by WHO in September 2023 in what the organisation has described as an “extraordinary achievement” amid the ongoing war in the country. But while experts have welcomed the end to the outbreak, they have warned of continuing serious challenges to immunisation efforts for other diseases. “Vaccination uptake for preventable diseases in Ukraine is low, and the main reason for this is the war,” Andrii Loboda (Department of Paediatrics, Sumy State University, Sumy, Ukraine) told The Lancet Microbe. Since the start of Russia's full-scale invasion of Ukraine in February 2022, experts have warned of the potential for major disease outbreaks in the country, citing risks posed by massive displacement of people, disruption of medicine supply lines, and destruction of health-care infrastructure. Meanwhile, conditions on the frontlines, where soldiers are repeatedly exposed to bad weather, poor hygiene, and a lack of infection controls, and suffer extreme stress (which can reduce immunity), have also elevated risks for disease spread. Although no new major outbreaks have been recorded since the beginning of the war, there are concerns this could soon change given the continuing fighting and its potential to disrupt provision and accessibility of vaccines. A polio vaccination catch-up campaign for children aged 6 months to 6 years had just got underway when the invasion began, and its speed and scope was subsequently impacted. “Damage or destruction of health facilities posed challenges in maintaining vaccination supply chain and cold chain logistics, while the displacement of millions of people led to major uncertainty in target population estimates for planning and implementing vaccination activities,” Dr Jarno Habicht, Head of the WHO Country Office (Kyiv, Ukraine), told The Lancet Microbe. Measles, which is endemic in Ukraine, is seen as a particular, and imminent, threat given the low vaccine coverage rate, which stood at 69% in 2022. Habicht said the “challenges of war” had contributed to the low rate. In a measles outbreak in 2017–19, over 115 000 people were infected and 41 died. Most infections were among individuals who were either unvaccinated or whose vaccination status was undetermined. In the first 8 months of 2023, 43 cases of measles have been recorded in Ukraine, whereas only 11 were reported in the whole of 2022. “The situation with measles is not good, we're not far from an outbreak. A catch-up measles campaign from June to September was not successful and measles vaccine uptake among children in Ukraine at the moment is low,” Alla Volokha (Shupyk National Healthcare University of Ukraine, Kyiv, Ukraine) told The Lancet Microbe. COVID-19 is another worry ahead of autumn and winter with Ukrainian Ministry of Health data showing only 3·5 million people in the country out of a total pre-war population of 43 million have had a vaccine booster dose. But coverage problems are not limited to a select few diseases. “We see problems with vaccine uptake for all preventable diseases, especially in regions near the frontline,” said Volokha. Ukrainian authorities have no access to populations in occupied territories and with information strictly controlled by occupying authorities, it is difficult to gauge the level of access to routine immunisation services. People (who prefer to remain anonymous) in some occupied areas who have spoken to The Lancet Microbe say that in many places health care is extremely limited or non-existent, and a health needs assessment conducted in September 2022 by WHO found that many children and adults in areas of active combat or beyond Ukrainian control were not accessing immunisation services. Health Ministry data also show the lowest vaccination rates for preventable diseases are in regions either occupied or seeing active fighting. However, it is not just the war that is hampering immunisation efforts. At the start of the 2017–19 outbreak, the national measles vaccine coverage rate was 42%, largely due to vaccine hesitancy, which the WHO admits remains a problem. “Issues around demand for and acceptance of routine vaccines in Ukraine influenced routine vaccination coverage even before the war,” said Habicht. A mother from Kyiv told The Lancet Microbe she had managed to keep her child, aged 6 years, up to date with all recommended vaccines despite the war and despite the frequent negative attitudes to vaccinations she encounters online and among people she knows. “There were a few interruptions to normal vaccine schedules because of the war, but we managed. I know some people talk about vaccinations being bad for you, but I believe in science and had no doubts about getting my daughter vaccinated,” she said. The Ukrainian Ministry of Health did not respond to questions from The Lancet Microbe, but has said it is committed to strengthening vaccine-preventable disease surveillance and working to expand routine immunisation coverage throughout the country.